Clinical Informatics Fellowship Programs: In Search of a Viable Financial Model: An open letter to the Centers for Medicare and Medicaid Services.

In the US, the new subspecialty of Clinical Informatics focuses on systems-level improvements in care delivery through the use of health information technology (HIT), data analytics, clinical decision support, data visualization and related tools. Clinical informatics is one of the first subspecialties in medicine open to physicians trained in any primary specialty. Clinical Informatics benefits patients and payers such as Medicare and Medicaid through its potential to reduce errors, increase safety, reduce costs, and improve care coordination and efficiency. Even though Clinical Informatics benefits patients and payers, because GME funding from the Centers for Medicare and Medicaid Services (CMS) has not grown at the same rate as training programs, the majority of the cost of training new Clinical Informaticians is currently paid by academic health science centers, which is unsustainable. To maintain the value of HIT investments by the government and health care organizations, we must train sufficient leaders in Clinical Informatics. In the best interest of patients, payers, and the US society, it is therefore critical to find viable financial models for Clinical Informatics fellowship programs. To support the development of adequate training programs in Clinical Informatics, we request that the Centers for Medicare and Medicaid Services (CMS) issue clarifying guidance that would allow accredited ACGME institutions to bill for clinical services delivered by fellows at the fellowship program site within their primary specialty.

Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the third annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine. Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine. Ann Emerg Med. May 2000;35:481-498.]

Report of the Task Force on Residency Training Information (1998-1999), American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. We present the second annual report on the status of US emergency medicine residency programs. [American Board of Emergency Medicine: Report of the Task Force on Residency Training Information (1998-1999), American Board of Emergency Medicine. Ann Emerg Med May 1999;33:529-545.]

American Board of Emergency Medicine Longitudinal Study of Emergency Physicians.

STUDY OBJECTIVE: The American Board of Emergency Medicine (ABEM) Longitudinal Study of Emergency Physicians (LSEP) was initiated to describe the development of a new medical specialty through the continuing study of the lives of representative emergency physicians. The study is designed to gather data periodically over many years to come. The primary purpose of this article is to provide a baseline for the information obtained and the methods used to develop the ABEM LSEP. METHODS: Stratified, random sampling was used to select emergency physicians who represent different stages in the development of the specialty. Major data collections are conducted using a comprehensive questionnaire in 5-year intervals. Practice profiles were developed and analyzed. Homogeneous scales were created in 9 survey categories and analyzed. RESULTS: The survey was returned by 95% (958/1,008) of the emergency physicians. They are primarily middle-aged, family- and community-oriented, satisfied with their careers, and find that work stress is not a serious problem. Those who are trained in emergency medicine are the most likely to be involved in academic emergency medicine. CONCLUSION: The LSEP is a broad-reaching investigation of emergency physicians. Over time the study will describe (1) the individuals who move the specialty forward at different stages in the growth of the specialty, (2) the realities of practice in the specialty, (3) the relationship of the specialty to the personal lives and well-being of the specialty physicians, and (4) the changes seen in these factors over time.

Report of the Task Force on Residency Training Information, American Board of Emergency Medicine.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residents and the programs in which they train. Before the compilation of this report, this information has not been widely available.

The future of the certification system in emergency medicine.

The heart of the specialty of emergency medicine, like all specialties and subspecialties, is training. The excellence in medical care that has accrued to the American public has proceeded from the belief that a well-defined and accredited program of education will produce the highest probability that a physician providing care will be competent. There is now a joint opportunity in emergency medicine to build a certification and recertification system that meets the criteria to provide the highest quality care for the public and to offer an efficient and effective system for the members of the specialty.

Longitudinal study of emergency physicians by the American Board of Emergency Medicine: 1995 interim survey results.

STUDY OBJECTIVE: To obtain current demographic data and information regarding the opinion of a stratified random sample of emergency physicians about the greatest current challenges facing emergency medicine. METHODS: An annual survey was conducted by the American Board of Emergency Medicine (ABEM) using a stratified random sample of 1,004 emergency physicians selected from four cohorts, 1979, 1984, 1988, and 1993. These samples were further divided between diplomates who had completed emergency medicine residency training and those who had not. The 1993 non-residency-trained panel was replaced by a random sample of American College of Emergency Physicians members who were full-time emergency physicians, were not ABEM diplomates, and had not completed a residency in emergency medicine. The interim survey instrument is a one-page collection of relevant demographic items selected from the comprehensive 5-year questionnaire with the addition of the open-ended question, "What are the greatest challenges facing emergency medicine today?" RESULTS: Of the interim surveys distributed, 95% (n = 956) were returned. Because the 1995 interim survey was the first distributed after the initial 1994 comprehensive survey, the demographic data had changed little. Such data will become increasingly important and useful as changes are reported over subsequent years. The main challenge identified by participants was the impact of managed care (31%), followed by economic and financial issues (23%). Personal impact issues, such as individual stress and malpractice, accounted for a smaller number of responses (18%). CONCLUSION: Overall, the ABEM Longitudinal Study participant responses to the 1995 interim survey describe a committed group of emergency physicians who are struggling and coping with the needs of a maturing specialty and with the crosscurrents and changes in American medicine.

The sensorineural specializations of the trunk tip (finger) of the Asian elephant, Elephas maximus.

BACKGROUND: The dorsal extension of the tip of the trunk of Asian elephants (Elephas maximus), often referred to as "the finger," possesses remarkable mechanical dexterity and is used for a variety of special behaviors including grasping food and tactile and ultimately chemosensory recognition via the vomeronasal organ. The present study describes a unique sensory innervation of this specialized region of the trunk. METHODS: The tip of the dorsal aspect of the trunk is referred to as the trunk tip finger and has been studied grossly in 13 living elephants. One tip from a male Asian elephant was obtained for histologic study when it was accidentally severed. The tissue was fixed in 10% neutral buffered formalin, and portions were either sectioned frozen or embedded in paraffin and serial sectioned. Sections were stained with silver in both cases. RESULTS: The skin of the trunk tip finger differs from that of the surrounding areas; it contains a high density of free nerve endings, numerous convoluted branched small corpuscles, and vellus vibrissae that resemble vellus hairs, which do not protrude beyond the skin surface. The finger is thus densely innervated with three distinctive types of sensory terminals. Corpuscular receptors consist of small Pacinian corpuscles and convoluted branched simple corpuscles. Both are present in the superficial dermis. Abundant regular vibrissae are present in the skin surrounding the trunk tip finger. Short vibrissae that do not protrude from the skin surface, referred to as vellus vibrissae, are abundant in the finger tip. Both types of vibrissae are innervated by hundreds of axons resembling the mystacial vibrissae of rodents. Free nerve endings are numerous in the superficial dermis, often making intimate contact with the basal cells of rete pegs. CONCLUSIONS: The dorsal finger of the trunk tip of Asian elephants has a unique sensory innervation that resembles aspects of sensory innervation of mystacial skin of rodents or lip tissue of monkeys. This dense sensory innervation can be correlated with the tactile ability of these animals to use the trunk finger to grasp small objects for feeding and to insert chemically active samples into the ductal orifices of the vomeronasal organ for subsequent chemosensory processing.

An experimental painful peripheral neuropathy due to nerve constriction. I. Axonal pathology in the sciatic nerve.

A constriction injury to the sciatic nerve of the rat produces a painful peripheral neuropathy that is similar to the conditions seen in man. The pathology of the sciatic nerve in these animals was examined at 10 days postinjury, when the abnormal pain sensations are near maximal severity. The nerves were examined with (1) complete series of silver-stained longitudinal sections of pieces of the nerve (3 cm or more) that contained the constriction injury in the center, (2) toluidine blue-stained semithin sections taken at least 1 cm proximal and 1 cm distal to the constriction, and (3) EM sections taken adjacent to those stained with toluidine blue. One centimeter or more proximal to the constriction, both myelinated and unmyelinated axons were all normal. Nearer to the constriction, extensive degeneration of myelinated axons became increasingly common, as did signs of endoneurial edema. Distal to the constriction, the nerve was uniformly edematous and full of myelinic degeneration. There was a profound loss of large myelinated axons and a distinctly less severe loss of small myelinated and unmyelinated axons. These observations show that at 10 days postinjury the constriction produces a partial and differential deafferentation of the sciatic nerve's territory. The absence of degeneration in the nerve 1 cm proximal to the constriction indicates the survival of the primary afferent neurons whose axons are interrupted.

The differentiation of the skin and its appendages. I. Normal development of papillary ridges.

In the present study, the normal development of papillary ridges was studied in the volar pads of both fore and hindpaws of the opossum, Monodelphis domesticus. At birth, the developmental state of the opossum's paws is equivalent to that of a six-week human embryo. The development of papillary ridges in the opossum occurs entirely postnatally and the hindpaw lags behind the forepaw by at least four days in most developmental parameters. Papillary ridge formation is preceded by four events: skin innervation, Merkel cell differentiation, mesenchymal condensation, and epidermal proliferation. The apical pads at the tips of the digits and the interdigital pads between the heads of the metacarpals (or metatarsals) have a unique pattern of innervation and mesenchymal content as compared to the non-pad skin. Each pad is innervated by a prominent nerve trunk and axons ascend towards the epidermis providing a density of innervation that exceeds that in the non-pad epidermis. Merkel cells are absent in non-pad epidermis but present in the pads prior to the onset of formation of papillary ridges. A loose aggregation of mesenchyme forms the core of the pads and the superficial dermis is more cellular in the pads as compared to the equivalent dermis in surrounding non-pad skin. Developing papillary ridges always contained Merkel cell-axon complexes. Merkel cell axon complexes serve as the anatomical substrate of slowly adapting (SA) mechanoreceptors. The presence of these complexes during early skin differentiation is consistent with the use of the opossum's forepaw in climbing to the nipple, but also suggests other possible functions. We hypothesize that the nervous system might play a role in the timing or patterning of the formation of papillary ridges.

The differentiation of the skin and its appendages. II. Altered development of papillary ridges following neuralectomy.

In order to test the hypothesis that the nervous system is an important determinant of skin differentiation, deletions of the left lumbosacral dorsal root ganglia (DRGs), the sources of cutaneous afferents to the left hindpaw, were performed on opossum pups at day 1 when hindpaws have just begun to be innervated. At birth, each lumbosacral DRG measures about 200 microns rostrocaudally and a deletion measuring 1 mm would span 4-5 DRGs. Following survival periods of 5-24 days, serial sections through the trunk documented partial left lumbosacral DRG deletion and a variable degree of spinal cord destruction. The blood supply to the trunk and hindpaws was preserved. Bilateral enlargement of residual DRGs was observed and regenerating skin at the site of the deletion was hyperplastic and hyperinnervated. The skin of the plantar pads of the hindpaws was studied following the neuralectomies. Statistically significant differences were observed between the left (experimental) and right (control) hindpaws. The density of innervation of the left hindpaw was reduced compared to the right hindpaw, development of papillary ridges was retarded by 3-4 days, and non-innervated Merkel cells were hypogranulated. This period of delay in ridge development is probably a reflection of the expansion of residual DRGs into the peripheral domains of deleted DRGs. The present study confirms a role for afferent nerves in the timing of cutaneous differentiation and a mutual trophic dependence between cutaneous nerves and Merkel cells in the epidermis.

Differentiation of the anterior body wall and truncal epidermis and associated co-migration of cutaneous nerves and mesenchyme.

The present study examines the relationship between the migration of mesenchyme and associated cutaneous nerves that are involved in the closure of the anterior body wall in embryonic mice and rats by light and electron microscopy. The sternum is formed by the migration of condensations of mesenchyme originating in the dorsolateral body wall known as sternal bands. In the course of analyzing this process in rodent embryos we have identified similar paired caudal extensions of the sternal bands that are responsible for the closure of the abdominal wall following resolution of the umbilical hernia, and we suggest these bands of mesoderm should be referred to as the abdominal bands. Both the sternal and abdominal bands are associated with the development of the segmental spinal nerves and their cutaneous terminal branches. The first cutaneous nerve to reach the skin surface in rats is the later cutaneous nerve (PCN and ACN) at E13.5 days. The ACN co-migrates with the sternal and abdominal bands, and terminal branches of axons from the ACN approach the epidermis during this migration. Differentiation of the epidermis could be recognized as a change in shape of epidermal cells from squamous to cuboidal, and this initial differentiation coincides with the onset of cutaneous innervation, beginning at the site of the LCN and following the extent of innervation of the PCN as well as the migration of the mesodermal bands and associated ACN. The paired ACN's meet in the ventral midline at E16.5 in rats as the sternal bands fuse, and terminal axons from both nerves densely innervate the midline skin.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravascular plastic catheters. How they potentiate tumor necrosis factor release and exacerbate complications associated with sepsis.

We tested the hypothesis that long-term intravascular cannulation exacerbates the harmful effects of an infectious challenge. Four groups of rats were initially studied: rats without intravascular catheters or infection (group 1), rats without catheters with a polymicrobial infection (group 2), rats with catheters but no infection (group 3), and rats with catheters and infection (group 4). Infected animals had an increased mortality and generated a significantly increased tumor necrosis factor response compared with noninfected animals. Animals with catheters and infection generated far less cardiac output than animals from the other three groups. No histologic changes differentiated the four groups. Therefore, the presence of a sterile intravascular catheter significantly increases cardiac dysfunction and mortality rates in rats with chronic bacteremia. These results suggest that intravascular plastic catheters potentiate the destructive cascade of events produced by the host in response to bacteremia.

Myotome and early neurogenesis in chick embryos.

The present study was undertaken in order to verify the identification of profiles of presumptive growth cones in vivo. The developing spinal nerves of chick embryos were studied by light and electron microscopy. We traced the onset of efferent and afferent innervation of the myotome in 2- to 4-day-old chick embryos in order to be sure that we were examining the growing tips of axons. In the process of studying these growing axons, we were able to observe some unique relationships of neural tube, myotome, and differentiating spinal nerves. The neural tube tightly abuts the myotome in Hamburger and Hamilton's (HH) stage 14 chick embryos and cytoplasmic projections from the myotome directly abut the neural tube. The first ventral roots could be identified in HH stage 15 embryos and dorsal roots in HH stage 16 embryos, both under 2 1/2 days of age. The advancing spinal nerve courses toward the anterior or cranial half of the myotome, and growth cones directly contact the medial wall of the myotome. The spinal nerves continue to abut tightly the myotome during the succeeding day of embryonic life, and growth cones enter the substance of the myotome by 3 days, or HH stage 19 embryos. These dorsolaterally directed axons will form the dorsal ramus of the spinal nerves and the ventral ramus continues to be contiguous with the myotome. Invasion of the myotome by axons (putative innervation), and thus innervation of myotomal cells in the 3-day chick embryos, was a totally unexpected finding. The myotome and its potential derivatives thus have extensive neural contact by 3 days of embryonic life in the chick. These findings document a parallel differentiation of afferent and efferent elements of the nervous system and confirm previous accounts identifying growth cones in an intact organism. These findings suggest that afferent as well as efferent nerves may have critical roles in the differentiation of the mesodermal as well as ectodermal derivatives.